NPIMap

Organization Active NPI

Retina Specialists of Idaho, PLLC

  • Ophthalmology Physician
  • Boise, ID
National Provider Identifier
1366607996
Registry record updated Apr 10, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
M-10066 Issued in ID
Legal business name
RETINA SPECIALISTS OF IDAHO, PLLC
Practice address
13923 W Wainwright Dr
Suite 301
Boise, ID 83713-1969
Phone
(208) 938-5624
Fax
(208) 938-5764
NPI assigned
Jul 23, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 10, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Denton R. Roberts, M.D.NPI 1699742395
Title
Owner
Phone
(208) 938-5624

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207W00000X M-10066 ID Primary

Addresses

Primary practice location

13923 W Wainwright Dr
Suite 301
Boise, ID 83713-1969

Mailing address

13923 W Wainwright Dr
Suite 301
Boise, ID 83713-1969
Phone (208) 398-5624

Other identifiers 1

IdentifierTypeStateIssuer
808025900MedicaidID

National Provider Directory

National Provider Directory

Locations

13923 W Wainwright Dr
Ste 301
Boise, ID 83713
Phone (208) 938-5624

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1216771200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1334016000000",
    "number": "1366607996",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13923 W WAINWRIGHT DR",
            "address_2": "SUITE 301",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837131969",
            "telephone_number": "208-398-5624",
            "fax_number": "208-938-5764"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13923 W WAINWRIGHT DR",
            "address_2": "SUITE 301",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837131969",
            "telephone_number": "208-938-5624",
            "fax_number": "208-938-5764"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RETINA SPECIALISTS OF IDAHO, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-23",
        "last_updated": "2012-04-10",
        "status": "A",
        "authorized_official_last_name": "ROBERTS",
        "authorized_official_first_name": "DENTON",
        "authorized_official_middle_name": "R.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-938-5624",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "ID",
            "license": "M-10066",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "808025900",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.